Female genital mutilation/cutting incidence, diagnostic capacities, and obstetric outcomes among migrant women: a single-center retrospective analysis in a 10-year birth cohort in Austria.

INTRODUCTION: Practical experience in the care of women with female genital mutilation/cutting (FGM/C) is uncommon in Austria. However, affected women require specialized gynecological and obstetric care. In our region, there is currently neither an official counseling center nor specially trained medical personnel to address the special needs of women after FGM/C. The aim of this study was to determine the potential need for obstetric care for women who have undergone FGM/C in our region. METHODS: We retrospectively reviewed women presenting for delivery at the LKH University Hospital Graz from 1.1.2010 until 31.12.2020 regarding the place of birth and/or the nationality of the mother to filter out women from a country with known FGM/C prevalence according to the UNICEF Global Database. Data on the documentation of FGM/C as well as demographic maternal data and peripartal parameters were gathered. Periods before and after the European refugee crisis in 2015 were compared. RESULTS: During the study period, a total of 35,628 deliveries took place at our hospital. 856 (2.4%) deliveries of 539 women were included due to nationality or birthplace in a country with known FGM/C prevalence. We found only 17/539 (3.2%) documented FGM/C cases. The estimated FGM/C prevalence among those patients was, however, 208/539 (38,6%). Women affected by FGM/C in our collective were most frequently from Nigeria, Egypt, Iraq, Ghana, and Somalia. No statistically significant increase in deliveries during the study period in the overall study cohort was observed, with the exception of deliveries of Somali women (p = 0.000). DISCUSSION: The discrepancy between documented and expected FGM/C rates (3,2% vs. 38,6%) in our collective suggests that most cases of FGM/C go undetected among women delivering in Austria. These data show the great need for special training for obstetricians and targeted contact points for affected women.

Unilateral inguinofemoral lymphadenectomy in patients with early-stage vulvar squamous cell carcinoma and a unilateral metastatic sentinel lymph node is safe.

OBJECTIVE: Optimal management of the contralateral groin in patients with early-stage vulvar squamous cell carcinoma (VSCC) and a metastatic unilateral inguinal sentinel lymph node (SN) is unclear. We analyzed patients who participated in GROINSS-V I or II to determine whether treatment of the contralateral groin can safely be omitted in patients with a unilateral metastatic SN. METHODS: We selected the patients with a unilateral metastatic SN from the GROINSS-V I and II databases. We determined the incidence of contralateral additional non-SN metastases in patients with unilateral SN-metastasis who underwent bilateral inguinofemoral lymphadenectomy (IFL). In those who underwent only ipsilateral groin treatment or no further treatment, we determined the incidence of contralateral groin recurrences during follow-up. RESULTS: Of 1912 patients with early-stage VSCC, 366 had a unilateral metastatic SN. Subsequently, 244 had an IFL or no treatment of the contralateral groin. In seven patients (7/244; 2.9% [95% CI: 1.4%-5.8%]) disease was diagnosed in the contralateral groin: five had contralateral non-SN metastasis at IFL and two developed an isolated contralateral groin recurrence after no further treatment. Five of them had a primary tumor ≥30 mm. Bilateral radiotherapy was administered in 122 patients, of whom one (1/122; 0.8% [95% CI: 0.1%-4.5%]) had a contralateral groin recurrence. CONCLUSION: The risk of contralateral lymph node metastases in patients with early-stage VSCC and a unilateral metastatic SN is low. It appears safe to limit groin treatment to unilateral IFL or inguinofemoral radiotherapy in these cases.

Prophylactic salpingectomy for prevention of ovarian cancer at the time of elective laparoscopic cholecystectomy.

BACKGROUND: Most serous ovarian cancers are now understood to originate in the fallopian tubes. Removing the tubes (salpingectomy) likely reduces the risk of developing high-grade serous ovarian cancer. Numerous gynaecological societies now recommend prophylactic (or opportunistic) salpingectomy at the time of gynaecological surgery in appropriate women, and this is widely done. Salpingectomy at the time of non-gynaecological surgery has not been explored and may present an opportunity for primary prevention of ovarian cancer. METHODS: This study investigated whether prophylactic salpingectomy with the intention of reducing the risk of developing ovarian cancer would be accepted and could be accomplished at the time of elective laparoscopic cholecystectomy. Women aged at least 45 years scheduled for elective laparoscopic cholecystectomy were recruited. They were counselled and offered prophylactic bilateral salpingectomy at the time of cholecystectomy. Outcome measures were rate of accomplishment of salpingectomy, time and procedural steps needed for salpingectomy, and complications. RESULTS: A total of 105 patients were included in the study. The rate of acceptance of salpingectomy was approximately 60 per cent. Salpingectomy was performed in 98 of 105 laparoscopic cholecystectomies (93·3 per cent) and not accomplished because of poor visibility or adhesions in seven (6·7 per cent). Median additional operating time was 13 (range 4-45) min. There were no complications attributable to salpingectomy. One patient presented with ovarian cancer 28 months after prophylactic salpingectomy; histological re-evaluation of the tubes showed a previously undetected, focal serous tubal intraepithelial carcinoma. CONCLUSION: Prophylactic salpingectomy can be done during elective laparoscopic cholecystectomy.

ANTECEDENTES: La mayoría de carcinomas serosos de ovario se originan en las trompas de Falopio. La exéresis de las trompas (salpingectomía) probablemente reduce el riesgo de desarrollar un carcinoma seroso ovárico de alto grado. Numerosas sociedades ginecológicas recomiendan efectuar una salpingectomía profiláctica (u oportunista) en el momento de una cirugía ginecológica en determinadas mujeres, y esta conducta está ampliamente difundida. Sin embargo, no se ha analizado la realización de la salpingectomía durante cirugías no ginecológicas como forma de prevención primaria del carcinoma ovárico. MÉTODOS: Determinar si la salpingectomía profiláctica con intención de reducir el riesgo de desarrollar cáncer de ovario sería aceptada y podría llevarse a cabo durante una colecistectomía laparoscópica electiva. Se reclutaron mujeres ≥ 45 años de edad programadas para colecistectomía laparoscópica electiva. A todas ellas se les aconsejó y ofreció la realización de una salpingectomía bilateral profiláctica en el momento de su colecistectomía. Las variables analizadas fueron la tasa de realización de la salpingectomía, la duración y las etapas quirúrgicos para efectuar este procedimiento, y las complicaciones. RESULTADOS: La aceptación de la salpingectomía fue aproximadamente del 60%. La salpingectomía se realizó en 98 de 105 colecistectomías laparoscópicas (93%) y no se pudo realizar en 7 pacientes (7%) por escasa visibilidad o adherencias. La mediana del tiempo quirúrgico adicional fue de 13 (rango 4-45) minutos. No hubo complicaciones atribuibles a la salpingectomía. Una paciente presentó cáncer de ovario 28 meses después de la salpingectomía profiláctica; la reevaluación histológica de las trompas mostró un carcinoma intraepitelial seroso focal tubárico (serous tubal intraepithelial carcinoma, STIC) no detectado previamente. CONCLUSIÓN: La salpingectomía profiláctica se puede realizar durante la colecistectomía laparoscópica electiva.

Correction to: The use of PIPAC (pressurized intraperitoneal aerosol chemotherapy) in gynecological oncology: a statement by the Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) Kommission Ovar, AGO Study Group, North-Eastern German Society of Gynaecologic Oncology (NOGGO), AGO Austria and AGO Switzerland.

The title of the article has been published incorrectly. The correct title is given below.

The use of PIPAC (pressurized intraperitoneal aerosol chemotherapy) in gynecological oncology: a statement by the "Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR)", the Swiss and Austrian AGO, and the North-Eastern German Society of Gynaecologic Oncology.

BACKGROUND: Ovarian, tubal, and peritoneal carcinomas primarily affect the peritoneal cavity, and they are typically diagnosed at an advanced tumor stage (Foley, Rauh-Hain, del Carmen in Oncology (Williston Park) 27:288-294, 2013). In the course of primary surgery, postoperative tumor residuals are, apart from the tumor stage, the strongest independent factors of prognosis (du Bois, Reuss, Pujade-Lauraine, Harter, Ray-Coquard, Pfisterer in Cancer 115:1234-1244, 2009). Due to improved surgical techniques, including the use of multi-visceral procedures, macroscopic tumor clearance can be achieved in oncological centers, in most cases (Harter, Muallem, Buhrmann et al in Gynecol Oncol 121:615-619, 2011). However, to date, it has not been shown that peritoneal carcinomatosis is, per se, an independent factor of prognosis or that it excludes the achievement of tumor clearance. Several studies have shown that a preceding drug therapy in peritoneal carcinomatosis could positively influence the overall prognosis (Trimbos, Trimbos, Vergote et al in J Natl Cancer Inst 95:105-112, 2003). In relapses of ovarian carcinoma, studies have shown that peritoneal carcinomatosis is a negative predictor of complete tumor resection; however, when it is possible to resect the tumor completely, peritoneal carcinomatosis does not play a role in the prognosis (Harter, Hahmann, Lueck et al in Ann Surg Oncol 16:1324-1330, 2009). RESULTS: PIPAC is a highly experimental method for treating patients with ovarian, tubal, and peritoneal cancer. To date, only three studies have investigated a total of 184 patients with peritoneal carcinomatosis (Grass, Vuagniaux, Teixeira-Farinha, Lehmann, Demartines, Hubner in Br J Surg 104:669-678, 2017). Only some of those studies were phase I/II studies that included PIPAC for patients with different indications and different cancer entities. It is important to keep in mind that the PIPAC approach is associated with relatively high toxicity. To date, no systematic dose-finding studies have been reported. Moreover, no studies have reported improvements in progression-free or overall survival associated with PIPAC therapy. CONCLUSIONS: Randomized phase III studies are required to evaluate the effect of this therapy compared to other standard treatments (sequential or simultaneous applications with systemic chemotherapy). In cases of ovarian, tubal, and peritoneal cancer, PIPAC should not be performed outside the framework of prospective, controlled studies.

Sentinel nodes in vulvar cancer: Long-term follow-up of the GROningen INternational Study on Sentinel nodes in Vulvar cancer (GROINSS-V) I.

OBJECTIVE: In 2008 GROINSS-V-I, the largest validation trial on the sentinel node (SN) procedure in vulvar cancer, showed that application of the SN-procedure in patients with early-stage vulvar cancer is safe. The current study aimed to evaluate long-term follow-up of these patients regarding recurrences and survival. METHODS: From 2000 until 2006 GROINSS-V-I included 377 patients with unifocal squamous cell carcinoma of the vulva (T1, <4 cm), who underwent the SN-procedure. Only in case of SN metastases an inguinofemoral lymphadenectomy was performed. For the present study follow-up was completed until March 2015. RESULTS: Themedian follow-up was 105 months (range 0­179). The overall local recurrence ratewas 27.2% at 5 years and 39.5% at 10 years after primary treatment, while for SN-negative patients 24.6% and 36.4%, and for SN-positive patients 33.2% and 46.4% respectively (p = 0.03). In 39/253 SN-negative patients (15.4%) an inguinofemoral lymphadenectomy was performed, because of a local recurrence. Isolated groin recurrence rate was 2.5% for SN-negative patients and 8.0% for SN-positive patients at 5 years. Disease-specific 10-year survival was 91% for SN-negative patients compared to 65% for SN-positive patients (p b .0001). For all patients, 10-year disease-specific survival decreased from 90% for patients without to 69% for patients with a local recurrence (p b .0001).

[Metastatic mechanisms of uterine malignancies and therapeutic consequences]. / Metastasierung von Malignomen des Uterus und therapeutische Konsequenzen.

Malignancies of the uterus metastasize by direct invasion of neighboring structures, lymphatically or hematogenously. Endometrial and cervical cancers lymphatically spread to the pelvic and para-aortic lymph nodes. For endometrial cancer the depth of myometrial invasion, lymphosvascular space involvement (LVSI) and a microcystic, elongated and fragmented (MELF) glandular invasion pattern are predictors for lymph node metastases. Metastases to the pelvic lymph nodes occur in approximately 10 % of endometrial cancer patients and in 30 % of these cases the para-aortic lymph nodes are also involved. Sentinel lymph node biopsy is possible for clinical stage I endometrial cancer and early stages of cervical cancer but is not yet routine. The presence of LVSI is considered to be the strongest predictor of distant metastases, particularly if assessed by immunohistochemistry with antibodies against factor VIII-related antigen or CD31. Endometrioid and clear cell carcinomas can hematogenously metastasize to the lungs, bones, liver and brain and can rarely be manifested as a solitary metastasis. In contrast, serous carcinomas can show extensive peritoneal spread. To date molecular biomarkers cannot predict the occurrence of distant metastasis. Overexpression of P53, p16 and L1CAM have been identified as negative prognostic factors and are associated with the prognostically unfavorable serous tumor type. The metastatic spread of squamous cell cervical cancer is strongly associated with tumor volume. Microinvasive carcinomas have a very low rate of parametrial and lymph node involvement and do not require radical hysterectomy. In contrast, lymph node metastases occur in up to 50 % of bulky stages IB and II cervical cancers. Distant metastases can occur in the lungs, liver, bones and brain. Molecular biomarkers have not been shown to predict metastatic spread. In well-differentiated adenocarcinoma of the cervix the pattern of invasion is strongly predictive for the presence of lymph node metastases, irrespective of tumor size and depth of invasion.

Vaginal prolapse surgery with transvaginal mesh: results of the Austrian registry.

INTRODUCTION AND HYPOTHESIS: Several mesh repair systems for pelvic organ prolapse (POP) were introduced into clinical practice with limited data on safety, complications or success rates, and impact on sexual function. The Austrian Urogynecology Working Group initiated a registry to assess the use of transvaginal mesh devices for POP repair. We looked at perioperative data, as well as outcomes at 3 and 12 months. METHODS: Between 2006 and 2010 a total of 20 gynecology departments in Austria participated in the Transvaginal Mesh Registry. Case report forms were completed to gather data on operations, the postoperative course, and results at 3 and 12 months. RESULTS: A total of 726 transvaginal procedures with 10 different transvaginal kits were registered. Intra- and perioperative complications were reported in 6.8%. The most common complication was increased intraoperative bleeding (2.2%). Bladder and bowel perforation occurred in 6 (0.8%) and 2 (0.3%) cases. Mesh exposure was seen in 11% at 3 and in 12% at 12 months. 24 (10%) previously asymptomatic patients developed bowel symptoms by 1 year. De novo bladder symptoms were reported in 39 (10%) at 3 and in 26 (11%) at 12 months. Dyspareunia was reported by 7% and 10% of 265 and 181 sexually active patients at 3 and 12 months postoperatively respectively. CONCLUSIONS: The 6.8% rate of intra- and perioperative complications is in line with previous reports. Visceral injury was rare. The 12% rate of mesh exposure is consistent with previous series.

Guidelines for the management of third and fourth degree perineal tears after vaginal birth from the Austrian Urogynecology Working Group.

The purpose of this guideline is to provide a decision aid for diagnosis, treatment, and follow-up of patients with major perineal tears and thus minimize the risk of persistent symptoms. In 2007, the "Guideline for the management of third and fourth degree perineal tears after vaginal birth" was established by members of the Austrian Urogynecologic Working Group (AUB). The guideline was updated in 2011, including literature published up to 30 November 2011. The DELPHI method was used to reach consensus. Evidence-based and consensus-based statements were defined for epidemiology, risk factors, classification, diagnosis, surgery, and follow-up of major perineal lacerations at vaginal birth.

[Intraoperative frozen sections in diseases of the female genital tract]. / Schnellschnittdiagnostik bei Erkrankungen des weiblichen Genitaltrakts.

Intraoperative frozen sections are particularly important for ovarian tumors because definitive preoperative histology is not possible. The diagnostic accuracy of frozen sections is highest for primary invasive ovarian carcinomas and benign ovarian lesions, followed by borderline tumors and poorest for ovarian metastases and rare neoplasms, such as germ cell tumors. Endometrial carcinoma should be diagnosed preoperatively by curettage or biopsy. For endometrioid endometrial carcinomas the indications for lymphadenectomy are often based on intraoperative assessment of the uterus. The differential diagnosis of low grade stromal neoplasms is based on myometrial invasion and can be supported by assessment of frozen sections as well as the diagnosis of other mesenchymal uterine tumors suspected of being malignant. Frozen sections of pelvic lymph nodes provide the possibility of immediate subsequent para-aortic lymphadenectomy in endometrial and cervical carcinomas but have recently lost importance. Sentinel node biopsy with intraoperative frozen section analysis is routinely performed only for vulval carcinoma. The German Association of Gynecological Oncology (AGO) recommends deferred diagnosis and a two stage surgical procedure for any doubtful intraoperative ovarian histology. Intraoperative frozen sections for endometrial carcinoma and lymphadenectomy specimens as well as for sentinel node biopsies are currently not recommended but are also not completely rejected.

[Transobturator tapes: better than TVT?]. / Transobturatorische Bänder: Besser als TVT?

Suburethral slings (or tapes) placed by a transobturator approach may be an alternative to established retropubic tension-free vaginal tapes. Comparisons are hampered by the number of available systems. Injury of the bladder, bowel and major vessels appears less frequent with transobturator systems whereas vaginal tape erosion and infectious complications appear to be more common. Results of adequately powered randomized trials are not yet available.

Incidental (Prophylactic) Salpingectomy at Benign Gynecologic Surgery and Cesarean Section: a Survey of Practice in Austria.

Introduction: Most serous ovarian cancers are now thought to originate in the fallopian tubes. This has raised the issue of performing incidental salpingectomy (also called elective, opportunistic, prophylactic or risk-reducing salpingectomy) at the time of benign gynecologic surgery or cesarean section. We conducted an online survey to ascertain the policies regarding incidental salpingectomy in Austria in late 2014. Material and Methods: All 75 departments of obstetrics and gynecology in public hospitals in Austria were surveyed for their policies regarding incidental salpingectomy at benign gynecologic surgery or cesarean section. Results: Sixty-six of 75 surveyed departments completed the questionnaire, resulting in a response rate of 88 %. Overall, 46 of 66 (70 %) units reported offering or recommending incidental salpingectomy at benign gynecologic surgery, 12 units (18 %) did not, and eight units (12 %) did not have a consistent policy. Salpingectomy was the preferred method for surgical sterilization, including sterilization at the time of cesarean section (71 % and 64 % of units, respectively). Conclusions: Incidental (elective, opportunistic, prophylactic, risk-reducing) salpingectomy is now widely offered at benign gynecologic surgery and cesarean section in Austria. Evidence for the role of the fallopian tubes in the origin of serous pelvic cancer has led to changes in clinical practice.

Indications and Route of Hysterectomy for Benign Diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015)

Background: Official guideline "indications and methods of hysterectomy" to assign indications for the different methods published and coordinated by the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (OEGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). Besides vaginal and abdominal hysterectomy, three additional techniques have been implemented due to the introduction of laparoscopy. Organ-sparing alternatives were also integrated. Methods: The guideline group consisted of 26 experts from Germany, Austria and Switzerland. Recommendations were developed using a structured consensus process and independent moderation. A systematic literature search and quality appraisal of benefits and harms of the therapeutic alternatives for symptomatic fibroids, dysfunctional bleeding and adenomyosis was done through MEDLINE up to 6/2014 focusing on systematic reviews and meta-analysis. Results: All types of hysterectomy led in studies to high rates of patient satisfaction. If possible, vaginal instead of abdominal hysterectomy should preferably be done. If a vaginal hysterectomy is not feasible, the possibility of a laparoscopic hysterectomy should be considered. An abdominal hysterectomy should only be done with a special indication. Organ-sparing interventions also led to high patient satisfaction rates, but contain the risk of symptom recurrence. Conclusion: As an aim, patients should be enabled to choose that therapeutic intervention for their benign disease of the uterus that convenes best to them and their personal life situation.

Long-term follow-up of infants of mothers with type 1 diabetes: evidence for hereditary and nonhereditary transmission of diabetes and precursors.

OBJECTIVE: To estimate the impact of type 1 diabetes during pregnancy on transgenerational genetically caused and/or fuel-mediated amplification of types 1 and 2 diabetes and to estimate the impact of elevated amniotic fluid insulin levels. RESEARCH DESIGN AND METHODS: A total of 75 white offspring of type 1 diabetic mothers and 49 control subjects of similar age and pubertal stage were examined at 5-15 years of age. All offspring had an oral glucose tolerance test. Glucose, insulin, and C-peptide were measured at 0, 30, 60, and 120 min after loading. Lipids and autoimmune antibodies were measured in fasting plasma. RESULTS: Of the 75 offspring, 4 (5.3%) had overt diabetes, and 16 of 71 (22.5%) had autoimmune antibodies. Offspring of diabetic mothers had significantly higher BMI; symmetry indexes; cholesterol, glucose, insulin, and C-peptide levels; and insulin resistance than control subjects. With the exception of cholesterol, these values were significantly elevated in offspring who had elevated amniotic fluid insulin levels (>8 microU/ml, >48 pmol/l) during pregnancy compared with normoinsulinemic offspring and control subjects. CONCLUSIONS: Offspring of type 1 diabetic mothers have an increased risk for diabetes later in life. The relative risk for type 1 and type 2 diabetes is 71.6 and 3.2, respectively. Type 2 diabetes-associated risk factors, such as high BMI; elevated glucose, insulin, and C-peptide levels; and insulin resistance, are related to the fetal metabolic experience in utero, as reflected by amniotic fluid insulin concentration.

Staging of cervical carcinomas. Comparison of body-coil magnetic resonance imaging and endorectal surface coil magnetic resonance imaging with histopathologic correlation.

RATIONALE AND OBJECTIVES: The authors evaluate the accuracy of magnetic resonance (MR) imaging with body coil and endorectal surface coil techniques in the staging of cervical carcinomas and compare these results with those obtained with clinical staging (International Federation of Gynecology and Obstetrics [FIGO] classification) and postsurgical histopathology. METHODS: Fifteen patients (average age, 48.6 years) with biopsy-proved cervical cancer were included in the study. After clinical staging (FIGO classification), MR imaging with body coil (BCMR) and subsequently with endorectal surface coil (ECMR) was performed. Using a 1.5-Tesla unit, axial and sagittal proton density weighted and spin echo T2-weighted and fast spin echo T2-weighted sequences were obtained with body and endorectal surface coil. During imaging analysis, special attention was paid to the uterine zones, the vaginal fornix, and the parametrial tissue. Ten patients were treated surgically (postsurgical histopathology was considered the gold standard), five patients, all clinically staged IIIb, underwent primary radiation therapy. RESULTS: Clinical staging with FIGO classification was accurate in 12 of 15 patients, and understaged in 2 and overstaged in 1 patient. Body coil MR showed accurate staging in 13 of 15 patients. Using this technique, understaging of 2 patients, both with only minimal tumor infiltration depth (< 8 mm), was performed. Endorectal surface coil MR was accurate in 14 of 15 patients missing minimal parametrial tumor infiltration in 1 patient. Histopathology (n = 10) revealed 3 patients with tumor stage T1b, 2 with stage T2a, and 5 patients with stage T2b. CONCLUSIONS: Although suggested by only a small number of patients, ECMR appears to be the most accurate modality for staging cervical carcinomas but seems to be unreliable in the detection of minimal tumor infiltration.

Magnetic resonance imaging in patients with gestational trophoblastic disease.

RATIONALE AND OBJECTIVES: The authors describe the magnetic resonance (MR) imaging characteristics in patients with gestational trophoblastic disease (GTD) before and after therapy and to correlate these findings with human gonadotropin levels and the specific histology of GTD. METHODS: Thirteen women (mean age, 30.1 years) with elevated human chorionic gonadotropin (HCG) levels and histologically proven GTD underwent MR examinations of the pelvis. Magnetic resonance imaging was performed on a 1.5-tesla unit. Axial and sagittal proton density-weighted and T2-weighted and sagittal T1-weighted sequences were obtained. Four patients underwent follow-up studies after 4 and 8 weeks to monitor the response to therapy. Gestational trophoblastic disease was histologically proven with curettage in 11 patients and with hysterectomy in two cases. RESULTS: Nine patients had a diffusely enlarged uterus with pathologic signal intensities. In four patients, a focal tumor mass was observed. All patients showed loss of the zonal anatomy of the uterus in at least one local area. In 11 patients, no uterus zones could be identified throughout the entire uterus. Pathologic dilated tumor vessels were evident in all patients. In all four cases in which follow-up imaging studies were obtained, uterus size, signal intensities, identification of uterus zones, and uterus vessels returned to normal. CONCLUSION: Magnetic resonance imaging shows trophoblastic tumor infiltration as diffuse uterus enlargement, focal tumor masses, loss of zonal anatomy of the uterus, and pathologic uterine vasculature; this seems to be the most reliable MR imaging finding in patients with GTD. No correlation was found between MR imaging changes and HCG levels or specific histologic types of GTD.

Contribution of the posterior compartment to the urinary continence mechanism.

OBJECTIVE: To describe the contribution of the posterior pelvic compartment to the urethral closure mechanism. METHODS: Urethral profilometry at rest and during stress was performed in 32 continent women before and after inserting a weighted (1 kg) posterior speculum to displace the posterior vaginal wall and levator ani muscles away from the bladder neck and the urethra. RESULTS: Insertion of the speculum decreased the pressure transmission ratios in the proximal quarter of urethra (from 81 to 76; P < .05) and the urethral closure pressure under stress in the proximal two urethral quarters (from 5 to -3 cm H2O in the first and from 12 to 0 cm H2O in the second urethral quarter; P < .05) in all 32 women. Before speculum insertion, 20 women had positive urethral closure pressure in the proximal urethra under stress, and 12 had negative urethral closure pressure in the proximal urethra under stress. In the 20 women with positive urethral closure pressures under stress in the proximal urethra without a speculum, the insertion of a posterior speculum decreased the pressure transmission ratios to the proximal urethral quarter (from 87 to 78; P < .05) and decreased the urethral closure pressures under stress in the proximal two urethral quarters (from 13 to -4 cm H2O in the first urethral quarter and from 24 to 2 cm H2O in the second urethral quarter; P < .01). In the 12 patients with negative urethral closure pressures under stress in the proximal urethra without a speculum, the profilometry values were unchanged by insertion of a speculum. CONCLUSION: These observations indicate that the posterior vaginal compartment may contribute to the closure mechanism of the proximal urethra in continent women.

Body mass index and outcome of incontinence surgery.

OBJECTIVE: To analyze the influence of body mass on the outcome of surgery for urinary incontinence. METHODS: Among 291 women operated on for stress incontinence, 187 (64%) were available for follow-up at 5 years. Eighty women had anterior colporrhaphy, 49 anterior colporrhaphy with needle suspension of the bladder neck, and 58 Burch colposuspension. Body mass index was calculated preoperatively and at follow-up. Women were classified as being of normal weight (body mass index [BMI] 20-25), overweight (BMI 26-30), or obese (BMI greater than 30). Reported continence rates were analyzed according to BMI for each operation and the BMIs of continent patients were compared with those of incontinent patients. RESULTS: The continence rates at 5-year follow-up for anterior colporrhaphy, anterior colporrhaphy with needle suspension of bladder neck, and Burch colposuspension were 58, 51, and 86%, respectively (P < .001). The continence rates did not differ significantly among the three BMI groups for each procedure. A statistical power of 26% was found for the hypothesis that the outcome of the procedures does not depend on BMI. The preoperative and postoperative BMIs of continent and incontinent women for each procedure did not differ significantly. CONCLUSION: We did not find preoperative obesity to be a risk factor for failure of incontinence surgery, but the power of our study was limited.

Microinvasive carcinoma of the cervix: site of first focus of invasion.

OBJECTIVE: To evaluate the topography of the first invasive focus in microinvasive squamous cell carcinoma of the uterine cervix. METHODS: We studied 120 formalin-fixed and paraffin-embedded cold-knife conization specimens processed as step-serial sections. Four types of microinvasion were distinguished according to site: type I (ectocervical outside the last cervical gland), type II (ectocervical between the external os and the last gland and in connection with the surface epithelium), type III (ectocervical between the external os and the last gland but deep in cervical glands), and type IV (intracervical and in connection with the surface epithelium). RESULTS: A total of 142 early invasive foci were seen in the 120 cones. A single focus was seen in 106 (88%) specimens, whereas 14 (12%) had more than one focus. The foci were classified as type I in 16 (11%), type II in 31 (22%), type III in 70 (49%), and type IV in 25 (18%) cases. CONCLUSION: One half of the early invasive foci originated at the surface epithelium (types I, II, IV), either at the ectocervix (types I, II) or in the endocervix (type IV).

Long-term effects of vaginal dissection on the innervation of the striated urethral sphincter.

OBJECTIVE: To study the long-term effects of vaginal dissection on the innervation of the striated urethral sphincter. METHODS: Perineal nerve terminal motor latency was measured before and 8 weeks and 1 year after anterior colporrhaphy, colpoperineoplasty, and vaginal hysterectomy in 33 women, 19 of whom also underwent endoscopic suspension of the bladder neck. RESULTS: In the entire series, the mean perineal nerve terminal motor latency was prolonged before surgery over that in normal continent women and further prolonged 8 weeks and 1 year postoperatively. In the subjects who underwent vaginal hysterectomy and anterior colporrhaphy, perineal motor latencies were not significantly prolonged at the 8-week postoperative follow-up and had almost returned to preoperative values 1 year later. However, in those who underwent additional endoscopic bladder neck suspension, perineal motor latencies were prolonged at both postoperative follow-up examinations. Perineal motor latencies were unchanged 1 year postoperatively in continent patients (N = 19) but were prolonged in incontinent patients (N = 14). CONCLUSION: Vaginal dissection, especially during endoscopic bladder neck suspension, can worsen preexisting perineal neuropathy in patients with pelvic relaxation and stress incontinence.